The early nineteenth-century literary figure, Thomas de Quincey, was an opium user. “The subtle powers lodged in this mighty drug,” he enthused, “tranquilize all irritations of the nervous system... stimulate the capacities of enjoyment... sustain through twenty-four hours the else drooping animal energies... O just, subtle and all-conquering opium... Thou only givest these gifts to man; and thou has the keys of Paradise.” An opiate-addicted patient of mine in Vancouver’s notorious drug ghetto said it more simply: “The reason I do drugs is so that I don’t feel the f...g feelings I feel when I don’t do drugs.”

The most abject and marginalized street addict is seeking nothing less than the Paradise the writer de Quincey rhapsodizes: a sense of comfort, vitality and freedom from pain. Drug addicted people want only what everyone else craves: peace, connection with self and others and the absence of distress. That this quest is doomed, that they are likely to sacrifice their health, their position in society and their dignity shows only how powerful is the desperation that drives them. What is the source of that despair? Why are they willing to risk illness and death for the sake of their habit? “I’m not afraid of death,” another patient told me. “I’m more afraid of life.”

In North America two commonplace assumptions inform social attitudes towards addiction. First, that addiction is a result of individual choice, or personal failure. That view underlies the legal approach towards substance dependence: if the behavior is a matter of conscious choice, it therefore makes sense to punish or deter it by means of legal sanctions, including incarceration for mere possession. The naïve Nancy Reagan-inspired billboards urging “Just Say No” also exemplified the choice hypothesis. A second, more humane view is the medical perspective that sees addiction as an inherited disease of the brain. This view has the virtue of not blaming the afflicted person—after all, people cannot help what genes they inherit—and it also offers the possibility of compassionate treatment.

What the choice and hereditary hypotheses share in common is that, right or wrong, they both take society off the hook. Neither compels us to consider what it may be about a person’s experience and social position that contributes to a predisposition for addiction. If in North America—as elsewhere—it is colonized minority populations that suffer a disproportionate share of addiction’s burden, it must be due to their faulty decision making or, at best, to their flawed genes. If, for example, addiction is determined mostly by biological heredity, we are spared from having to look at how our social environment supports, or does not support, the parents of young children; at how social attitudes, prejudices and policies burden, stress and exclude certain segments of the population and thereby increase their propensity for addiction. The writer Louis Menard said it well in a New Yorker article:
“It’s all in the genes”: an explanation for the way things are that does not threaten the way things are. Why should someone feel unhappy or engage in antisocial behavior when that person is living in the freest and most prosperous nation on earth? It can’t be the system! There must be a flaw in the wiring somewhere.

The reality is starker. Addictions always originate in unhappiness, even if hidden. They are emotional anesthetics; they numb pain. The first question—always—is not “Why the addiction?” but “Why the pain?” The answer, ever the same, is scrawled with crude eloquence on the wall of my patient Anna’s room at the Portland Hotel in the heart of Vancouver’s Downtown Eastside: “Any place I went to, I wasn’t wanted. And that bites large.”

The Downtown Eastside is considered to be Canada’s drug capital, with an addict population of 3,000 to 5,000 individuals. According to a recent New York Times article, even visitors from the urban ghettos of the U.S. find Vancouver’s drug gulag shocking.

For twelve years I was staff physician at the Portland, a non-profit, harm-reduction facility where most of the clients are addicted to cocaine, to alcohol, to opiates like heroin, or to tranquilizers -- or to any combination of these things Many also suffer from mental illness. Like Anna, a 32-year-old poet, many are HIV positive or have full-blown AIDS. The methadone I prescribe for their opiate dependence does little for the emotional anguish compressed in every heartbeat of these driven souls. Methadone staves off the torment of opiate withdrawal, but, unlike heroin, it does not create a “high” for regular users.

The essence of that high was best expressed by a 27-year-old sex-trade worker. “The first time I did heroin,” she said, “it felt like a warm, soft hug.” In a phrase, she summed up the psychological and chemical cravings that make some people vulnerable to substance dependence.

No drug is, in itself, addictive. Only about 8 per cent to 15 per cent of people who try, say alcohol or marijuana, go on to addictive use. What makes them vulnerable? Neither physiological predispositions nor individual moral failures explain drug addictions. Chemical and emotional vulnerability are the products of life experience, according to current brain research and developmental psychology. Most human-brain growth occurs following birth; physical and emotional interactions determine much of our brain development. Each brain’s circuitry and chemistry reflects individual life experiences as much as inherited tendencies.

For any drug to work in the brain, the nerve cells have to have receptors—sites where the drug can bind. We have opiate receptors because our brain has natural opiate-like substances, called endorphins. These are chemicals that participate in many functions, including the regulation of pain and mood. Similarly, tranquilizers of the benzodiazepine class, such as Valium, exert their effect at the brain’s natural benzodiazepine receptors. Infant rats who get less grooming from their mothers have fewer natural benzo receptors in the part of the brain that controls anxiety. Brains of infant monkeys separated from their mothers for only a few days are measurably deficient in the key neurochemical, dopamine. It is the same with human beings. Endorphins are released in the infant’s brain when there are warm, non-stressed, calm interactions with the parenting figures. Endorphins, in turn, promote the growth of receptors and nerve cells, and the discharge of other important brain chemicals. The fewer endorphin-enhancing experiences in infancy and early childhood, the greater the need for external sources. Hence, the greater vulnerability to addictions.

Distinguishing skid row addicts is the extreme degree of stress they had to endure early in life. Almost all women now inhabiting Canada’s addiction capital suffered sexual assaults in childhood, as did many of the males. Childhood memories of serial abandonment or severe physical and psychological abuse are common. The histories of my Portland patients tell of pain upon pain.

Carl, a 36-year-old native, was banished from one foster home after another, had dishwashing liquid poured down his throat for using foul language at age 5, and was tied to a chair in a dark room to control his hyperactivity. When angry at himself—as he was recently, for using cocaine—he gouges his foot with a knife as punishment. His facial expression was that of a terrorized urchin who had just broken some family law and feared draconian retribution. I reassured him I wasn’t his foster parent, and that he didn’t owe it to me not to screw up.

But what of families where there was not abuse, but love, where parents did their best to provide their children with a secure, nurturing home? One also sees addictions arising in such families. The unseen factor here is the stress the parents themselves lived under, even if they did not recognize it. That stress could come from relationship problems, or from outside circumstances such as economic pressure or political disruption. The most frequent source of hidden stress is the parents’ own childhood histories that saddled them with emotional baggage they had never become conscious of. What we are not aware of in ourselves, we pass on to our children. Stressed, anxious, or depressed parents have great difficulty initiating enough of those emotionally rewarding, endorphin-liberating interactions with their children. Later in life such children may experience a hit of heroin as the “warm, soft hug” my patient described: What they didn’t get enough of before, they can now inject.

The U.S.-based Adverse Childhood Experiences studies have demonstrated beyond doubt that childhood stresses, including factors such as abuse, addiction in the family, a rancorous divorce, and so on, provide the template for addictions later in life. It doesn’t follow, of course, that all addicts were abused or that all abused children become addicts, but the correlations are inescapable.

If we look closely, we’ll see that addictive patterns characterize the behaviors of many members of society, including high-functioning and respectable middle class citizens. As a workaholic doctor, I’ve had my own non-substance addiction, to feverish professional activity and also to shopping. In my case, I can trace that back to emotional losses I suffered as a Jewish infant in Nazi-occupied Hungary during the last years of World War II. My children, in turn, were subjected to the stresses of a family headed by a workaholic father who was physically present but emotionally absent—a dynamic the psychologist Alan Schore has aptly called “proximal separation.”

Another major factor feeding addiction in our society is the loss of the traditional attachment network—of clan, tribe, village, extended family—and their replacement by a powerful but immature and seductive peer culture. Studies are clear that the peer group—enhanced these days by the technology of social networking—is the most common context for young people’s introduction to drug use.

Feeling alone, feeling there has never been anyone with whom to share their deepest emotions, is universal among drug addicts. That is what Anna had lamented on her wall. No matter how much love a parent has, the child does not experience being wanted unless he or she is made absolutely safe to express exactly how unhappy, or angry, or hate-filled he or she may at times feel. The sense of unconditional love, of being fully accepted even when most ornery, is what no addict ever experienced in childhood—often not because the parents did not have it to give, but simply because they did not know how to transmit it to the child.

Addicts rarely make the connection between troubled childhood experiences and self-harming habits. They blame themselves—and that is the greatest wound of all, being cut off from their natural self-compassion. “I was hit a lot,” 40-year-old Wayne says, “but I asked for it. Then I made some stupid decisions.” And would he hit a child, no matter how much that child “asked for it”? Would he blame that child for “stupid decisions”? Wayne looks away. “I don’t want to talk about that crap,” says this tough man, who has worked on oil-rigs and construction sites and served 15 years in jail for robbery. He looks away and wipes tears from his eyes.

Gabor Maté is a Vancouver physician and the author of In The Realm of Hungry Ghosts: Close Encounters With Addiction, from which this article was adapted. Reprinted with permission from YES MAGAZINE.